For a medical insurance claim settlement, a disease cannot be said to be pre-existing unless it has been certified so by a doctor on the basis of tests prior to the purchase of a policy, a consumer forum has held.
The disease could not be said to be pre-existing if it was merely opined so by the doctor on the basis of talks with the patient, the forum said while asking the National Insurance Co Ltd to pay Rs 75,000 to a policy holder for rejecting his claim for reimbursement of his wife’s treatment expenses.
“The disease in order to be pre-existing should be in the knowledge of the insured,” the New Delhi District Consumer Disputes Redressal Forum said. “If a doctor, on talking with a patient, gives a particular name to a condition explained by the patient, it is not sufficient as a positive evidence of pre-existing disease for the purpose of insurance,” the bench said.
The forum’s order came on the plea of Delhi resident Padam Sain Dhingra, who had alleged the insurance firm had rejected his claim of Rs 50,000 incurred by him on treatment of his wife.
Saying the company “arbitrarily repudiated the claim”, the bench directed it to pay the Rs 50,000 and also pay Rs 25,000 as compensation for harassment and litigation expenses.